Countdown to revalidation

After years of delays revalidation is set to be introduced at the end of this year. Helen Jaques looks at the road map to implementation and the possible stumbling blocks

Most doctors in the United Kingdom do not have to prove their fitness to practise at any time in their career except the point at which they join the medical register. Professionals in other high risk industries, with aviation being the most frequently cited, are expected to prove on a regular basis that their performance, knowledge, and skills are up to date. Many members of the public assume that the same applies to doctors.[1] In the wake of the Shipman inquiry, a government white paper concluded that more needed to be done to assure the quality of doctors’ practice.[1][2] It recommended that doctors prove their fitness to practise every five years, and thus the concept of revalidation was born.

Timeline to introduction

Revalidation requires doctors to complete an appraisal each year, including providing supporting information to show how they are meeting the professional values set out by the GMC, and then every five years to seek multisource feedback from colleagues and patients. Organisations that employ or contract medical practitioners—“designated bodies” in revalidation parlance—have been asked to assess and improve their clinical governance structures ahead of revalidation to ensure that doctors undergo effective annual appraisals and can get hold of the supporting information they need.

The results of the 2010-11 organisational readiness self assessment (ORSA) in England and Wales, published in October last year,[3][4] and the interim readiness assessments up to 31 December 2011 show good progress towards implementation of revalidation, says Anita Donley, medical director for the NHS Revalidation Support Team, which is in charge of delivering revalidation in England. As at 31 December 2011 three quarters (77%) of doctors were linked to a designated body that was either ready or expected to be ready by December 2012. Two thirds (63%) of designated bodies had appropriate appraisal policies in place—up from 52% in the 2010-11 ORSA—and 70% of organisations were confident that they had enough trained appraisers.

Over this summer the national delivery boards of each of the four nations of the UK will review the state of readiness in their country and will in September submit an assessment of whether they’re prepared for revalidation to begin in late 2012. The same month the UK Revalidation Programme Board will form a UK-wide collective recommendation that it will present to the General Medical Council’s governing council, which will subsequently make a recommendation to the health secretary for England, Andrew Lansley, as to whether the legislation for revalidation should go ahead (figure
).

Timeline to introduction of revalidation

Donley says that the Revalidation Programme Board is confident that revalidation will be launched this year as planned. “The time is now; it’s not about waiting again, it’s too important—to wait any longer would be wrong,” she said. Peter Rubin, chairman of the General Medical Council (GMC), is similarly certain that revalidation will be implemented in 2012. “We’re more conscious than anybody that this has been a very long journey, but we’re very confident that this is going to go ahead,” he said. “The public expects it to happen.”

Presuming that this all runs without a hitch, the first doctors to be revalidated at the end of 2012 will be the (senior) level 2 “responsible officers,” such as the chiefs of the strategic health authority clusters. (Responsible officers are senior doctors, in many cases medical directors of designated bodies, who are in charge of recommending whether doctors should be revalidated and for ensuring that appraisal systems are up to scratch.) The next doctors through the gates will be level 1 responsible officers in place at designated bodies. By April 2013 all responsible officers will be expected to start making recommendations for revalidation, with around 20% of doctors expected to be revalidated by April 2014. The vast majority of doctors will have been revalidated by the end of March 2016.

Exactly which doctors will be first up for revalidation next year varies across the UK, although the GMC hopes to inform this first cohort of their revalidation date in December. In England, for example, responsible officers will randomly select a sample of doctors or will select according to locally determined criteria, such as doctors with management or leadership roles or doctors who comply with the minimum requirements for the currency and relevance of supporting information (or a combination of both approaches). Scotland will be randomly nominating doctors for revalidation on the basis of their GMC registration numbers, with doctors who have either 4 or 6 as the penultimate digit of their GMC registration number being the first to be revalidated.

Issues to be resolved

Organisations such as the BMA are concerned that several details in the plans may need to be fixed before revalidation can be introduced.[5] In a letter to the Department of Health and the GMC, the association warned about outstanding problems with the supporting information required for revalidation, not least the multisource feedback process that doctors are expected to use to seek feedback from patients and colleagues; the time and resources needed to complete revalidation; and the provision for remediation.

Requirements for supporting information

To prepare for revalidation doctors need to bring to their annual appraisals supporting information to show how they are meeting the professional values set out in the GMC’s guidance Good Medical Practice. Doctors will need to bring six types of supporting information at least once in each five year revalidation cycle:

Evidence of continuing professional development

Evidence of quality improvement activity

Data on significant events

Feedback from colleagues

Feedback from patients, and

A review of complaints and compliments.

To provide some of these types of evidence doctors will need to draw information out of their employers’ clinical governance systems. The BMA is concerned, however, that many clinical governance systems are not up to this task and that doctors might themselves have to dig up this supporting information. The GMC has emphasised, though, that doctors won’t be prevented from being revalidated if their employer fails to provide this supporting information.[6] “We know there are concerns about what sort of information can be made available to doctors in terms of the current technology,” said Rubin. “Some of the more complicated clinical outcome measures will not be widely available, and it would clearly be unreasonable to expect doctors to bring something that is simply not available at their organisation.”

Doctors themselves should kick up a fuss if they find that their organisation isn’t providing the data they need for their supporting information, advises Donley. “What doctors should be doing really is engaging with the information available to them—and with sources that are difficult to access they should be making a fuss about it and drawing the attention of the designated body to the fact that it is difficult to get hold of information,” she said.

The BMA is also concerned about how feedback from patients and colleagues will be collected. The GMC has recommended that doctors seek feedback from up to 45 consecutive patients (minimum 34) and 20 colleagues (minimum 15) to complete revalidation.[7] The BMA’s General Practitioners Committee has called this “an enormous paper chasing exercise” that could eat into time for clinical care.

Rubin emphasises, however, that doctors need only collect multisource feedback once every five years. He acknowledges that collecting feedback and ensuring anonymity of responses may be difficult in some environments, such as for locums and in rural areas, but has said that the GMC will take a “pragmatic” approach. “We’re not going to be rigid about this,” he says. “We know that doctors work in all sorts of different environments, so the last thing we want to do is insist on a one size fits all approach.”

Time and resourcing

Gathering all this information, as well as the actual appraisal process itself, is likely to be time consuming. Pathfinder pilots of revalidation among more than 3000 doctors in England found that doctors spent between 12 and 18 hours collating and summarising information for their appraisal, an additional 4-10 hours on top of their current preparation for appraisal.[8]

The Academy of Medical Royal Colleges has recommended that hospital consultants need 1.5 supporting professional activity (SPA) sessions a week to do all the activities required for appraisal, which the BMA says could prove a problem given the erosion of SPAs by many employers, NHS trusts, and health boards.[9] “It is also currently unclear whether GPs will be provided with the extra resources and therefore time that they will need to complete the process,” the association has said.

The framework to be used for appraisal has been simplified since the pilots were completed, said Donley, making the process simpler and, hopefully, less time consuming. “Strengthened medical appraisal, which was a process that pre-dated the current process, was exhaustively mapped to each attribute of Good Medical Practice, but [applying this framework] was felt by doctors and others to be onerous,” she said. “The guidance and requirements now refer to the four domains of the Good Medical Practice framework rather than an exhaustive mapping to each attribute within each domain.” Even if it is assumed that doctors will need to spend an extra four or five hours on their appraisal, this time will be spread over a whole year, adds Rubin (box 1). “If you do this work as you’re going along and record things as you’re going along it does make life so much easier.”

Remediation

Logic suggests that if all doctors are subjected to greater scrutiny as a result of revalidation, more will be identified as needing to improve their practice. However, the results of the 2010-11 ORSA indicated that remediation of doctors identified by the appraisal and revalidation process as struggling might be a problem. Although most designated bodies (83.2%) had a process for investigating concerns about a doctor’s practice, only a third (30.2%) had a policy in place for re-skilling, rehabilitation, remediation, and targeted support. The BMA has said that it is “still far from clear” how remediation will work in practice and who will be responsible for its delivery and funding.

Revalidation has really “shone a light” on the adequacy, consistency, and fairness of remediation for doctors and on the preparedness of the health sector to deal with issues affecting doctors’ fitness to practise, said Donley. She pointed out that the NHS Revalidation Support Team has recently published guidance on remediation that identifies and signposts good practice and refers to processes, ways of categorising risk, and ways of providing the generic support functions needed for remediation (box 2).[10] “What the guidance suggests is having a consistent, fair, and equitable process across England that identifies the generic functions that would need to be provided to an assured level to provide that,” she said.

Box 1: What you need to do to prepare

If a doctor is engaged in appraisal and is part of a good clinical governance system, he or she should be meeting most of the requirements for revalidation already, says Anita Donley, medical director for the NHS Revalidation Support Team. “Responsible doctors should constantly be in a process of examining the safety and quality of their practice, their own fitness to practise, and the safety and quality of the care that they provide to patients,” she said. “That in a sense is not something that is peculiar to the process of individual appraisal and revalidation: it’s part of a professional and ethical responsibility, it’s something about being a doctor.”

Doctors can do a few things to prepare, though, not least looking at the GMC’s website to see what is required for revalidation and thinking about how they can obtain that information in their own working environment, says Peter Rubin, the GMC’s chairman.

It’s also important to plan ahead over the whole five year revalidation cycle and not leave things to the last minute. “With planning and spreading the work over a period of time, the whole thing becomes very manageable,” said Rubin. “If you’re not using an e-portfolio, start using one, because it makes it so much easier to keep everything up to date and show what you’ve done that year in terms of things like CME [continuing medical education], rather than scrabbling around in the few weeks before your appraisal wondering where the bits of paper are.”

Donley recommends that doctors take into account all areas of their practice, not just the clinical areas, when preparing for appraisal and revalidation. “I will be submitting to my annual appraisal reflections on the whole of my scope of practice, which will include activities like medical management and leadership as well as my practice as an acute physician in Plymouth Hospital NHS Trust,” she pointed out.

The final countdown

The GMC acknowledges that there may be some teething troubles when revalidation is implemented, and it is avoiding a “big bang” introduction so that organisations have the slack to identify and resolve problems early on. “We at the GMC really, really want this to work well and run smoothly and for it not to be a bureaucratic burden on doctors who are already working very hard,” said Rubin. “Inevitably there will be unexpected challenges, but I think five years from now people will be wondering what all the fuss was about. It will be accepted as a part of normal working life, and people will get on with it.”

The GMC knows that most doctors in this country are very good, he added. “[Revalidation] is about enabling good doctors to enhance their practice [and] to reflect on their practice and improve further,” he said. “I would encourage doctors to view revalidation in that spirit.”

Box 2: Important guidance for doctors from the General Medical Council’s website